Friday, October 23, 2009
Wednesday, July 8, 2009
A Doctor by Choice, a Businessman by Necessity By SANDEEP JAUHAR, M.D.
I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.
A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.
Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We’ve heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.
It is doubtful that doctors and other medical professionals would voluntarily cut their own income (even if some of it is generated by profligate spending). Most doctors I know say they are not paid enough. Their practices are like cars on a hill with the parking brake on. Looking on, you don’t realize how much force is being applied just to maintain stasis.
I recently spoke with a friend who dropped out of medical school 20 years ago to pursue investment banking. Whenever we meet, he finds a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.
At our most recent meeting, we talked about the tumult on Wall Street. Like many bankers, he was worried about the future. “It is a good time to be a doctor,” he said yet again, as I recall. “I’d love a job where I didn’t have to constantly think about money.”
I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”
The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession.
Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naïve,” he said. “I never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”
I asked him how he felt about going into private practice. “I’ll be too busy vomiting for the first six months — I won’t have much time to think about it,” he replied.
Of course, there has always been a profit motive in medicine. Doctors who own their own imaging machines order more imaging tests; to take an example from my moonlighting work, a doctor who owns a scanner is seven times as likely as other doctors to refer a patient for a scan. In regions where there are more doctors, there is more per capita use of doctors’ services and testing. Supply often dictates demand.
But financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid.
At hospitals, uncompensated care is increasing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures — big moneymakers — are declining. Hospitals are cutting administrative costs, staff and services.
“More and more you’ll see people in medicine get M.B.A.’s,” a doctor told me at a seminar, in a prediction borne out in my experience. “We are in a total crisis, and I don’t know the answer.”
I must admit that part of me wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, I am nauseated by the blatant profiteering. As a loyal member of my guild, I want to see doctors exert more control over our financial house.
And yet the consequences of this commercial consciousness are troubling. Among my colleagues I sense an emotional emptiness created by the relentless consideration of money. Most doctors went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. We strove for so long, made so many sacrifices, and for what? In the end, for many, the job has become only that — a job.
Until I went into practice, I never had an interest in the business side of medicine. I sometimes yearn to be a resident or fellow again, discussing the intricacies of a case rather than worrying about the bottom line. “You need to learn a little of the private-practice mind-set,” a doctor friend recently advised me. “You can’t survive with your head in the clouds.”
But something fundamental is lost when doctors start thinking of medicine as a business. In their essay, Dr. Hartzband and Dr. Groopman talk about the erosion of collegiality, cooperation and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.
How this battle plays out will determine to a great extent what medicine will look like in 20 years. This is about much more than dollars and cents. It is a battle for the soul of medicine.
Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”
Thursday, March 26, 2009
Thursday, February 12, 2009
Saturday, January 31, 2009
Saturday, December 20, 2008
Recently I conducted a neuroanaesthesia test for our DNB students. It was designed to test their depth of understanding of fundamental concepts of anaesthesia for neurosurgery. By the way, Chintan, the topper got a prize from our HOD, Dr. Muralidhar.
If you want the answer key to this quiz, you will have to leave a comment.
Answer all questions. There is no negative marking. MCQs can have more than one correct answer and all the answer should be correct to get a mark.
Time: 45 mins
Brain represents ___ % of body weight and receives about ____ % of cardiac output. Oxygen consumption of brain is about ___ ml/ 100 gms of brain tissue per minute, so total brain oxygen consumption constitutes about ____ % of total body oxygen utilization.
3. Normal ICP is __________
4. What can you understand by the illustration shown below
5. Two components of cerebral metabolic activity are
6. CMR decreases by _____ per °C of temperature reduction
7. Why isn’t it a good idea to rapidly normalize PaCO2 in a patient who has had a prolonged period of hyperventilation?
8. What do these different waveforms represent?(Name the different waveforms)
9. Main energy substrate used for energy production is ________
10. What is inverse steal phenomenon?
11. Complete the following table which shows the effects of anesthetics on CBF and CMRO2( Increase = ‘+’ , decrease = ‘–‘ and No change = '0' )
N20 with IV agents
12. “Pulsatality index” is measured by which monitoring modality _____________
13. What do you know about Near Infrared Spectroscopy?
14. Rationale of using beta blockers as premedication in neuroanaesthesia ____________
15. The following monitoring techniques are used to detect venous air embolism. Arrange them in decreasing order of sensitivity
a. Pulmonary artery catheter
d. Precordial Doppler
e. Mass spectrometry of ETN2
16. During preanaesthetic evaluation of a head injury patient you notice that he has flexion withdrawal response and is making some incomprehensible sounds. He doesn’t open his eyes even on painful stimulus. What is his GCS score?
17. Methods to control intracranial hypertension (at least four).
18. All the following are true about GABA except
a. GABA is inhibitory neurotransmitter
b. There are two major types of GABA receptors- GABAA and GABAB
c. GABAA acts by opening chloride channels and GABAB acts by opening potassium channels
d. Barbiturates and Benzodiazepines act by enhancing action at GABAB
19. All are true about cerebral autoregulation except
a. It occurs between 50-150 mm Hg
b. It is a Myogenic response
c. Occurs immediately after the pressure change
d. Range of autoregulation is shifted to a higher pressure in hypertensives
e. Abolished by trauma, hypoxia, and inhalational anesthetics
20. All the following are true about CSF except
a. It is formed at a rate of 0.3-0.4ml /min allowing complete replacement 3-4 times a day
b. One of the three major components that occupy the space in skull, with other two being brain(neurons and glia) and Blood perfusing the brain
c. Furosemide and acetazolamide doesn’t decrease CSF production
d. Formed by choroid plexus epithelial cells
e. Has a higher protein concentration than serum
21. When the brain is stiff (low compliance) and enlarged, ICP
a. rises only minimally when the patient coughs
b. rises significantly with a small increase in arterial CO2
c. is unaffected by arterial desaturation (hypoxia)
d. falls if the patient is put in the head-down position
e. rises if the head is twisted to the left or right
22. Cerebral perfusion pressure (CPP)
i. is satisfactory if more than 70 mmHg in a patient with a head injury
ii. is calculated by adding mean arterial pressure (MAP) and ICP
iii. falls if arterial BP falls following induction of anaesthesia
b. when low should be treated by infusing dextrose-saline solution
23. All the following processes protect against ischemic damage of brain except,
a. Maintaining normal blood flow
b. Reducing metabolic rate, thereby maintaining ATP levels
c. Scavenging free radicals
d. Increasing intracellular concentration of sodium and calcium
e. Facilitating release of excitatory amino acids
24. Following a severe head injury, ICP will rise to damaging levels if
a. the patient develops airway obstruction
b. the patient becomes severely hypertensive
c. the patient is allowed to breathe halothane spontaneously during an anaesthetic
d. arterial hypoxemia occurs
e. the patient suffers severe pain from other injuries which is not treated
25. All the following are true with respect to focal ischemia of brain tissue except.
a. There are three regions in the ischemic zone
b. “Penumbra” is a region of normal blood flow
c. Inverse steal is beneficial in focal ischemia of brain tissue
d. Apoptosis occurs at less compromised region of ischemia and necrosis occurs at the core of ischemic area
26. All the following are true about effects of inhalational anesthetics on CBF except
a. Isoflurane and sevoflurane are the ideal volatile anesthetics for neurosurgery
b. Desflurane is recommended for space occupying lesions
c. Induction doses of sevoflurane( 1.5-2 MAC) causes epileptiform seizures in some patients
d. Volatile agents abolish PCO2 reactivity of CBF
27. Concerning intravenous agents
a. ketamine has no effect on ICP
b. thiopentone reduces ICP by direct cerebral vasoconstriction
c. a moderate fall in arterial BP following thiopentone in a patient with cerebral decompensation (raised ICP) need not be treated immediately
d. propofol does not effect cerebral metabolic rate
e. the patient will recover rapidly when anaesthesia has been maintained by a thiopentone infusion
a. Generated by pyramidal cells of granular cortex
b. Deep sleep and deep anaesthesia produce delta waves
c. Theta waves are high frequency, low amplitude waves seen in awake adults
d. Indicated intraoperatively in detection of cerebral ischemia, assessment of pharmacologic interventions(burst suppression) and brain death, diagnosis and management of intractable epilepsy
e. Plot of voltage against time
f. Frequency increased by high dose of intravenous agents like thiopentone, propofol, BZDs and etomidate
29. All the following are true about Sensory evoked potentials except,
a. There are three modalities – SSEPs, BAEPs, VEPs
b. Individual peaks are described in terms of amplitude, latency and polarity
c. For SSEP – 50% reduction in amplitude is clinically significant
d. Evoked potential of brainstem origin are more vulnerable anesthetic influence when compared to those of cortical origin
e. VEPs arise from the brain stem
f. Volatile agents cause dose dependent increase in latency and decrease in amplitude of cortical evoked potentials
a. Given IV in the dose of 0.25 – 1 gm/kg; action begins within 10-12 minutes and lasts for 2 hours
b. Larger doses produce longer duration of action
c. Is effective only when BBB is intact
d. Should be given rapidly for it to attain its peak onset of action early
e. Can cause a rebound increase of ICP
f. Prolonged use of mannitol may produce dehydration, electrolyte disturbances, hyperosmolality, and impaired renal function
31. About jugular bulb venous oximetry all are true except,
a. Estimates balance between cerebral oxygen demand and supply
b. Normal SjVO2 is 60-70%
c. Changes in oxygenation of systemic blood influences SjVO2
d. SjVO2 increases to >75% during ischemic injury
e. It doesn’t detect focal ischemia
32. Wakeup test
a. Commonly used in scoliosis surgery to identify reversible damage to CNS by spinal distraction
b. Patient is woken up after complete reversal of muscle relaxation
c. Patient “awareness” is one of the adverse effects of the test
d. TIVA is the anesthetic technique of choice
33. In semi sitting position all are true except
a. Reduced venous return to the heart
b. Increased chances of venous air embolism due to sub atmospheric pressures in cerebral veins and dural sinuses
c. Pressure transducer should be kept at the level of external auditory meatus
d. Spontaneous ventilation is better than controlled, since the latter further reduces the venous return
e. Provides very good access to posterior fossa tumors
34. White matter receives more blood than grey matter, since it plays a crucial role in the normal functioning of grey matter – T / F
35. Optimum burst suppression is obtained more commonly by thiopentone when compared to other anaesthetic agents. T / F
36. Cerebral oxygen consumption decreases above 420 C. T/ F and why?
37. The magnitude of CBF reduction with Hypocapnia is greater during volatile anaesthetic. T / F and why?
38. Resting membrane potential of a neuron is nearer to the equilibrium potential of sodium. T/F
39. Children have higher CMRO2 than adults. T/F
40. Muscle relaxant can be given in just adequate doses while monitoring cranial nerves. T/F
41. Mill wheel murmur is one of the very useful early signs of venous air embolism. T/F